A national survey on seclusion and restraint in state psychiatric hospitals

OBJECTIVES: State psychiatric hospitals across the U.S. were surveyed to develop national normative data on the incidence of seclusion and restrain and of injuries to patients and staff resulting from aggression by patients. METHODS: A survey instrument was sent to 225 state hospitals requesting information for a one-year period on the number of patients placed in seclusion or restraint, the number of discrete incidents of seclusion and restraint, the number of hours patients spent in seclusion or restraint, and the number of injuries to patients and staff attributable to aggression by patients. Rates of seclusion, restraint, and injuries were calculated to control for variation in hospital censuses. Percentile ranks for the various rates were calculated to allow hospitals to compare their rates. RESULTS AND CONCLUSIONS: A total of 101 state hospitals in 44 states and the District of Columbia returned the survey. In general, smaller hospitals had higher rates of seclusion and restraint. However, large standard deviations in the mean rates suggested considerable variability between hospitals in the sample. Small positive correlations between rates of seclusion and rates of restraint suggested that the hospitals did not use of the two interventions exclusively.     

Conditions for women in in-patient psychiatric units: the Mental Health Act Commission 1996 national visit

All NHS services are expected to make in-patient wards single-sex. However, as LESLEY WARNER and RICHARD FORD report, women in psychiatric hospitals still have to share sleeping accommodation with men, and still experience sexual harassment, violence, threat and abuse. Some units are unable even to guarantee 24-hour access to a female member of staff.     

Society before and after the introduction of psychotropic drugs for therapeutic use

In spite of a part of unavoidable subjectivity, it seems that the use of antidepressive, anxiolytic and hypnotic agents has increased over the past years, but with a certain recent stabilization in the consumption of benzodiazepines. A slipping towards the medicalization of problems yet principally social is generally admitted. The following factors are specially considered: the type of request of the person, often dominated by a behaviour of "relieved" people; the medical answers, frequently marked with a preferential if not exclusive rest on the chemical molecule; the financial limitations imposed by the national level, very probable indirect origin of changes in the medical status and role, therefore of distortions concerning the therapeutic relation; a contrario, marketing phenomena involved in large economic challenges. In front of that conflict situation, we must hope for a keeping of the liberty of exercise of the physician, for the benefit of the patient.     

One day survey by the Mental Health Act Commission of acute adult psychiatric inpatient wards in England and Wales

OBJECTIVES: To provide (via the Mental Health Act Commission's "national visit") empirical evidence on ward occupancy levels, use of the Mental Health Act 1983, nurse staffing, and care of female patients on acute adult psychiatric wards. DESIGN: One day survey of a stratified random sample. SETTINGS: 119/250 (47%) acute adult psychiatric inpatient units in England and Wales. SUBJECTS: End sample of 263 acute psychiatric inpatient wards. MAIN OUTCOME MEASURES: Ward occupancy rates; number of patients detained under the Mental Health Act and proportion "absent without leave"; nurse staffing levels, skill mix, and vacancies;proportion of women with self contained, women-only facilities. RESULTS: Mean ward occupancy was 99% (95% confidence interval 97% to 102%). A ward mean of 30% (28% to 32%) of patients were detained under the Mental Health Act; of all detained patients, 1% (1% to 2%) were absent without leave. A ward mean of 0.3 (0.29 to 0.31) nurses were on duty per patient at the time of the visit. An estimated ward mean of 31% (30% to 32%) of nurse staffing may have been through casual contracts--higher in inner (48% (43% to 53%)) and outer London (45% (41% to 48%)). On 26% (21% to 32%) of wards, there were no nurses interacting with patients. A ward mean of 36% (30% to 41%) of female patients had self contained, women-only facilities. CONCLUSIONS: Attention should focus on improving the quality of acute inpatient psychiatric care as well as of community care.     

A discussion of problems in interpretation of the Mental Health Act

On the basis of their experience as psychiatrists, and observations of Mental Health Act influence on mutual relationships between psychiatrists, their patients and patients family members, the authors analyze situations in which strict, appliance of the law may be harmful, or, for other reasons, ethically doubtful. They suggest that the Mental Health Act is too meticulous in regulating the procedures regarding mentally disturbed persons. According to the law indications, motives for treatment without consent are more often social or behavioral rather than strictly medical. It limits the ability to help a lot of people who really require psychiatric care. Authors indirectly suggest that it is impossible to replace ethics and doctors' conscience by the law.     

Social factors and compulsory detention of psychiatric patients in the U.K. The role of the approved social worker in the 1983 Mental Health Act

Low-density lipoprotein (LDL) is known to be a mitogenic factor for vascular smooth muscle cells (VSMCs), fibroblasts, and endothelial cells. In the current study, we describe possible intracellular mechanisms by which LDL elicits its mitogenic effects. Stimulation of VSMCs with LDL resulted in a pertussis-toxin (PTX)-sensitive stimulation of the 44-kDa mitogen-activated protein (MAP) kinase (p44(mapk)) and 42-kDa MAP kinase (p42(mapk)) isoforms as well as in a PTX-sensitive increase in intracellular free Ca2+ concentration ([Ca2+]i). Binding of the LDL-induced increase in [Ca2+]i to the intracellular Ca2+ chelator bis(2-amino-5-methylphenoxy)ethane-N,N,N',N'-tetraacetic acid tetraacetoxymethyl ester resulted in a 2-fold increase in the phosphorylated p44(mapk) and p42(mapk) isoforms but did not influence the LDL effect of VSMC DNA synthesis. PD 98059, a MAP kinase kinase inhibitor, remarkably attenuated the LDL-induced activation of MAP kinases and DNA synthesis. Treatment of normal human skin fibroblasts and human fibroblasts isolated from patients with familial hypercholesterolemia homozygote class 1 mutations, which are not able to produce the classic LDL receptor, resulted also in a PTX-sensitive increase in cell DNA synthesis and stimulation of the p44(mapk) and p42(mapk) isoforms in both cell types. These results demonstrate that the mitogenic effect of LDL is mediated by a PTX-sensitive Gi-coupled receptor that is independent of its classic receptor and involves activation of MAP kinase isoforms. Furthermore, the mitogenic effect of LDL may be mediated by the activation of the MAP kinase pathway. In contrast, the LDL-induced increase in [Ca2+]i may be implicated in this process only in conjugation with other signaling components.     

Mental health and substance abuse benefits in carve-out plans and the Mental Health Parity Act of 1996

Legislation passed in the fall of 1996 required employers and insurers offering mental health benefits to raise dollar coverage limits on mental health services to the level of medical services. We analyze the benefit designs of 4,000 current behavioral health carve-out plans and contrast them to medical benefits. We find that almost 90 percent of all plans are inconsistent with the current legislation and need to be rewritten in the coming year. The restructuring of designs required by the Parity Act provides a unique opportunity because plans often are inconsistent and unnecessarily complex, a legacy of past attempts by employers to contain costs and control adverse selection and moral hazard in an unmanaged fee-for-service environment. Under managed care, the need for deductibles, limits, or other demand-side cost-sharing mechanisms may have diminished and restructuring outdated designs could benefit both enrollees and employers.     

The future of psychiatric hospitals in Ontario

The purpose of this paper is to review past and present roles and to speculate on the future of the Ontario provincial psychiatric hospitals (PPHs). Currently, and for the very immediate future only, there are 10 PPHs that are owned and operated by the Ministry of Health of Ontario, each serving a specified population ranging from 250,000 to over 3,000,000. In addition to clinical expertise, provincial psychiatric hospitals contribute greatly to teaching and research. Ontario's mental health reform movement has called for a shift of resources to the community and a downsizing of PPHs by 2003. In response to fiscal pressures, in 1996 provincial legislation was passed to establish the Health Services Restructuring Commission (HSRC) as a stand-alone corporation with powers to restructure and reengineer health services in Ontario. The HSRC has to date recommended the closure of 4 PPHs by 1999 and the integration of theses services into other medical facilities. While a rebalancing of the mental health system does need to take place, the fiscally driven haste to close hospitals has created a crisis atmosphere in PPHs for staff and patients. It is also unlikely that the necessary community resources will be in place to buffer these changes. The new restructuring plans not only set unrealistic timelines, they seem to underestimate the importance PPHs have played in teaching, research and the advancement of clinical treatment and rehabilitation of the severely mentally ill. It may be that, in the long run, service integration and divestment/closure of the PPHs will result in better access to services closer to smaller communities and in the destigmatization of the mentally ill, however, without close evaluative monitoring and appropriate leadership, it could also lead to decreased research, training and quality of care.     

Analysis of the Truth and Responsibility in Mental Health Practices Act and similar proposals.

A version of the so-called Truth and Responsibility in Mental Health Practices Act was introduced in New Hampshire's Legislature in 1995. The American Psychological Association (APA) Practice Directorate analyzed the legislation with the assistance of the law firm of Hogan and Hartson and, convinced of its potentially harmful impact on the public and the profession, assisted New Hampshire and other states in combating such misleading and harmful legislation. Anticipating that such legislation will continue to be introduced, the authors include analyses that will assist readers in understanding and dealing with the problems such legislation poses. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sensitization to human leukocyte antigen before and after the introduction of erythropoietin

A hydrophobic, redox-active component with a molecular mass of 538 Da was isolated from lyophilized membranes of Methanosarcina mazei G?1 by extraction with isooctane. After purification on a high-performance liquid chromatography column, the chemical structure was analyzed by mass spectroscopy and nuclear magnetic resonance studies. The component was called methanophenazine and represents a 2-hydroxyphenazine derivative which is connected via an ether bridge to a polyisoprenoid side chain. Since methanophenazine was almost insoluble in aqueous buffers, water-soluble phenazine derivatives were tested for their ability to interact with membrane-bound enzymes involved in electron transport and energy conservation. The purified F42OH2 dehydrogenase from M. mazei G?1 showed highest activity with 2-hydroxyphenazine and 2-bromophenazine as electron acceptors when F420H2 was added. Phenazine-1-carboxylic acid and phenazine proved to be less effective. The Km values for 2-hydroxyphenazine and phenazine were 35 and 250 microM, respectively. 2-Hydroxyphenazine was also reduced by molecular hydrogen catalyzed by an F420-nonreactive hydrogenase which is present in washed membrane preparations. Furthermore, the membrane-bound heterodisulfide reductase was able to use reduced 2-hydroxyphenazine as an electron donor for the reduction of CoB-S-S-CoM. Considering all these results, it is reasonable to assume that methanophenazine plays an important role in vivo in membrane-bound electron transport of M. mazei G?1.     

The 1983 Mental Health Act in five local authorities: a study of the practice of approved social workers

This paper represents the first report of an ongoing collaborative project and charts the activities of social workers undertaking their duties within the framework of the 1983 Mental Health Act in five English Local Authorities for one year. Social workers are involved in a range of duties under the Act, but most commonly they are involved in assessments with a view to compulsory detention. The characteristics of people assessed are examined, and a profile emerges of vulnerable subgroups, typically younger men, older women, and people living in socially impoverished situations. Considerable variation between Authorities is found in terms of numbers of assessments, and in numbers of detentions. Low levels of 'diversion' into alternative care are identified. Comparisons are made with a major national study which took place four years earlier. Higher rates of detention are found on average, but lower rates of use of emergency provision (Section 4). An examination of the organisational context within which Approved Social Workers (ASWs) practice reveals a great deal of variation between authorities in terms of the ongoing experience of assessments available to ASWs. Social workers based in Emergency Duty Teams and Hospital Teams are compared, and a distinctive profile of their work emerges, the hospital-based ASWs being more likely to be assessing 'known' people, often already in hospital, and referred for assessment by consultants. The implications of these findings for the management and deployment of Approved Social Workers are briefly discussed. The emphasis is upon the role of the ASW in terms of balancing the rights and needs of people assessed under the Act.     

Psychiatric hospitalization of senile and arteriosclerotic dementia patients by commitment order under the 1991 Israeli Mental Health Act

Data regarding commitment orders issued by district psychiatrists for elderly patients aged 65 years or older were obtained from the national psychiatric case register. Out of a total of 2,284 commitment orders issued in Israel in the period 1 January 1992 to 30 June 1993 under the 1991 Mental Health Act, 191 (8.3%) involved patients aged 65 and over; these orders were issued for the commitment of 169 patients who suffered from the following ICD-9-CM diagnoses on discharge: senile and arteriosclerotic dementia; transient organic psychotic conditions; schizophrenic disorders; affective psychoses; paranoid states; or other psychiatric disorders. Demographic and clinical characteristics of the senile and arteriosclerotic dementia patients were compared with the same variables in the other diagnostic categories. Results showed that (a) involuntary commitment of senile and arteriosclerotic dementia patients involved a small minority of dementia sufferers; (b) it was usually the patients' first psychiatric admission; (c) most of the patients were discharged within a one-month period; and (d) most of the patients were referred for continuation of treatment in non-psychiatric institutions. Findings (c) and (d) characterized other diagnostic categories as well. The relevance of these findings to the Mental Health Act is discussed.     

The role of the psychiatric nurse--oppressed and oppressor]

This work aims at analysing the role of the psychiatric nurse in assisting the hospitalized mentally ill, viewing that practice not in itself, but as a social and historical one. An empirical research was done in two psychiatric hospitals in two stages: field observations and interviews with nurses. It was checked that the emphasis the role of the psychiatric nurse is not in therapeutic relationship but in administratives activities and that the relationship the members of the nursing team have with the patient is authoritarian and reproduce the authoritarism of the institutions. Thus the precepts of school that says the chief role of the nurse is the therapeutic relationship seem to have an ideological character. That makes us suggest that the teaching-learning relationships must be established on a praxis basis.     

The use of unregulated workers in Toronto hospitals

Violence is obscured by habits of thought, which predispose us to reject that which falls outside of our notion of "normal" human behavior. By dismissing as incomprehensible, or "pathologic," embodied practices that do not correspond to a "rationally ordered" everyday life, some anthropologists concerned with issues of violence forsake a fundamental responsibility to foster an understanding of phenomena that affronts, offends, or questions our own cultural norms and assumptions. Situations of violence, whether due to contextual or individual instability, by definition defy pregiven notions of "rationality" and "normal behavior." This article is about Palestinian martyrs, youths killed in confrontations with the Israeli military. It seeks to identify the cultural and psychological processes that make Palestinian martyrdom possible within the specific context of Israeli military occupation. It elaborates the ritual, narrative, and symbolic dimensions of a practice that exists within a Palestinian discourse of sacrifice and of national liberation.     

Background and prospects of the Community Health Act

Japan was defeated in World War II and almost all of the nation was demoralized by the destruction and damage to much of the nation. The medical and health care system during and before World War II needed to be reformed radically and fundamentally since almost all medical and health institutes were destroyed. On the other hand, many health personnel came back from overseas after the war. Japanese modern medicine had developed on the basis of German medicine; however, many aspects of American medicine, including public health and democracy, were rapidly introduced following the end of World War II. The American type of health center was established and many laws concerning medical and health care were enacted in 1947-1948. One of them was "The Health Center Law." The National Health Insurance Act was enacted in 1958 and the total population has been covered by health insurance plans since 1961. Many physicians quit the health centers and they have worked as clinicians under the National Health Insurance scheme, because health centers were introduced before adequate education and research existed in the field of public health. On the other hand, the health insurance scheme was in its golden age during the high economic growth period of the 1960s. Japan has succeeded in all forms of modern technology and economy for the past 30 years and is now one of the top nations in the field of medical and health care, such as the numbers of clinics and hospitals and beds, the frequency of consulting with a doctor, length of hospital stay, examinee rates in mass health examinations in the community and workplace and so on. Health conditions have changed drastically from the 1950s to the present. Therefore, health centers do not fit current health needs. For example, mortality from tuberculosis, acute infections diseases and also stomach and uterus cancers and apoplexy have decreased rapidly while mortality from chronic diseases, especially lung, breast and rectal cancers, and myocardial infarction have increased gradually. Changes of life style resulting from rapid economic growth are suspected to be important causes of the change in the prevalence of these diseases. Mass health examination was important and effective as a preventive measure against tuberculosis, especially as a means of early detection and early treatment. However, it is not now effective against chronic diseases. The screening examination has resulted in identifying many patients suspected of being ill. Every examiner must be able to distinguish pathologic findings from physiologic changes of aging. Every patient must, therefore, understand his/her individuality and evaluate the result of his/her efforts to improve life style by receiving a health examination. Accordingly, the aim of health examination has changed from early detection to health support for the examinee. During the decades when life expectancy was less than 50 years of age, it was not necessary for people to plan for retirement. Moreover, there was little burden on younger generations to provide care for the aged people because there were few old people more than 70 years of age and the birth rate was high. Nowadays, elderly people face many years of life after retirement and there are too many aged people in relation to the number of younger persons. As for medical care services, many new medical needs have emerged in recent years, including "quality of life," "palliative medicine in terminal care," "establishment of a primary care system" and "comprehensive care connecting health and medical care with welfare" etc. Improved living standards resulting from economic growth, called the "economic miracle" internationally, have helped to bring about a rapid and wide range of change in daily lifestyle, such as eating habits, working conditions and environment. The Ministry of Health and Welfare has made every effort to revise the laws in relation to health and medical care systems, in order to adjust to recent     

Esophageal scintigraphy of Zenker''s diverticula before and after diverticulotomy]

To assess the role of insulin in the development of obesity induced by antipsychotic drugs, a glucose tolerance test was conducted in 40 female rats during the peak of sulpiride-induced weight gain and in 40 vehicle-treated animals. The glucose area under the curve did not differ between the groups (P = 0.24), however, the area under the insulin curve was significantly decreased by sulpiride (55.2 +/- 2.8 versus 115.6 +/- 18.9, P = 0.007). The results suggest that insulin resistance and hyperinsulinaemia are not involved in the excessive weight gain observed in this animal model of drug-induced obesity. Alternatively, the insulin-dampened response observed in the sulpiride-treated rats may be related to increased insulin sensitivity, which may promote weight gain as proposed by Ravussin (1995).